REGISTRATION

PLEASE READ THE FOLLOWING CAREFULLY BEFORE PROCEEDING:

For the past 30 years, the CEC has been very pleased to evaluate cases from around the world, at no cost to the patient, in an effort to help the international endometriosis community connect with better care. Given the vast time and effort our surgeons dedicate to the review and procedural planning process with each patient who sends their case, however, we ask that only those individuals who are committed to potentially pursuing treatment here at our Center send their files for review. We appreciate your understanding.

We do not accept record packages for review by email; please refrain from emailing any case documents to the CEC staff or our surgeons. Please follow the instructions you will receive after registering to ensure a timely review of your case file.

The registration form below is for new records review cases only. If you have registered previously but did not send your case and would like to do so now, please first check to see if we have your prior registration on file before registering again. Please do not register if you are an existing CEC patient (current or any year prior) or have (or plan to schedule) an in-office appointment. If you are an existing CEC patient (from any year) in need of assistance, please call us at 770-913-0001 and we'll be delighted to help you. If you were looking to book an in-office appointment (consult costs will apply), please note appointments are not made online and you should not register for the records review; instead, please call us at 770-913-0001 and our staff will be delighted to book you and review the dates available/costs of your visit/insurance aspects with you. Thank you.

How the registration process works: every registration is responded to by email (or postal mail if email - the preferred method - is not available) with an information packet containing next steps, instructions, and all the necessary details and requirements for the free records review. The email packet is usually sent within 24-48 hours after you've registered unless temporary delays are specifically noted. If you do not receive your e-packet, please check your spam file.If you receive an email from one of our surgeons but not your packet of instructions, that means the mail went to your blocked/spam file or was otherwise not delivered by your email provider. Please check and notify us accordingly if you still did not receive it by sending a message to Heather@CenterForEndo.com.

GDPR/Privacy: we take your privacy very seriously. By proceeding with the following registration data input, we will collect personal information about you, including but not limited to your name, address, email and phone number. We will use your data only to personalize your correspondence with us, administer your case, and provide any products and/or materials and/or services you have requested from us. All information is held in the strictest of confidence; no third parties have access to your data except as directed by law. All information collected herein is stored on protected servers. To learn more about our privacy policy, please click here. By proceeding with your registration input, you acknowledge this privacy notice and afford permission for the CEC staff and/or its assigns to contact you as outlined above.

Please understand that we cannot process any case file reviews on an 'urgent' basis. You can expect the process to take upwards of 7-14 days from the time the records are received. Please also note that incomplete or incorrect registrations will significantly delay processing of your file (e.g. incorrect email address, missing fields, etc.).

We are so glad you're here, and we look forward to hopefully being able to help! Thank you for taking the time to complete your form.

Patient's legal first & last name *

Patient's middle initial (write 'n/a' if not applicable) *

Patient's preferred name, if different from legal name above (for example: legal name "Jane Doe"; prefers to be called "Jill Doe")

Maiden/other name patient's medical records may be in

Patient's mailing address (street/PO box/mailstop/etc.) *

City, state, postal code (country if outside USA) *

Age *

Date of birth *

Date of birth

MM

DD

YYYY

Phone number (country code if outside USA)-required *

Phone number (country code if outside USA)-required

Country

(###)

###

####

Email (this is where your packet will be sent; please double-check your entry and be sure to add 'centerforendo.com' to your permitted senders list) *

If any, name of insurance company & their phone #

If insured, full name including middle initial and date of birth of policy holder